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| | Key Paper Summaries IDD
Cost Effectiveness
| Kumar K,
Hunter G, Demeria DD |
| Treatment of chronic pain by using intrathecal
drug therapy compared with conventional pain therapies: a cost-effectiveness
analysis. J Neurosurg 2002; 97: 803-10 |
| Method |
- Intrathecal drug therapy (IDT) administered
in carefully selected patients with chronic pain has proven to be an
effective means of controlling pain, improving quality of life (QoL),
increasing the rate of work rehabilitation and minimizing long-term
costs of healthcare.
- However, at present there is limited
published literature available analyzing the cost-benefit ratio,
nowadays an essential step in treatment planning.
- The aim of this study was to compare the
cost-effectiveness of IDT in patients who respond to treatment compared
with conventional pain therapy (CPT) in patients with chronic low back
pain caused by failed back syndrome.
- A series of 67 patients within the Canadian
healthcare system were assessed, 23 of whom underwent implantation of
a programmable drug delivery pump (SynchroMed, Medtronic). The remainder
formed the control group.
- During a 5-year period, actual (not computer-generated)
costs (Canadian dollars) for diagnostic imaging, professional fees,
implantation costs, nursing visits for maintenance of the pumps, alternative
therapies and hospitalization costs for breakthrough pain were tabulated.
- From this data, cumulative costs were
calculated and compared with those in the control group.
- The influence of these treatments on QoL
was also analyzed (Oswestry Disability Index).
|
| Results |
- During the 5-year follow-up period, actual
cumulative costs for IDT ($29,410) were much lower than for CPT ($38,000).
- Mean annual costs were $5,882 in the
IDT group, compared with $7,600 in the CPT group.
- High initial costs of equipment required for
IDT were recovered by 28 months.
- After this time point, managing
patients with CPT became the more expensive treatment option for
the remainder of the follow-up period.
- The Oswestry Disability Index showed at 27%
improvement in QoL for patients in the IDT group, compared with
a 12% improvement in the control group.
- 60% of IDT patients were very satisfied
with their treatment.
- Unlike the IDT group, no patient
in the CPT group was able to return to work.
|
| Discussion/Conclusion |
- In patients who respond to treatment, IDT is
cost effective in the long term, despite the high initial costs of implantable
devices.
- This holds true even when considering worst-case
scenarios in which multiple complications may be involved.
- Additional benefits of IDT included increased
ability to work and improved QoL with better pain control.
- Further cost savings should result from
technological advances that increase the life span of the pumps, and
improvements in catheter design that will decrease the incidence of
their fracture, occlusion and detachment.
|
| Mohadjer
M, Bahls M, Winkelmüller W, Paduch T, Blumberg H. |
| Cost-Benefit Analysis of Implanted Drug-Pump
for the Treatment of Non-Malignant Chronic Pain. Abstract of the European
Medical Continuing Education (ECMT) course on Chronic Back and Leg Pain
(CBLP) given in Sintra, Portugal in November 2000 |
| Method |
- A total of 40 patients were selected from 300
who had been treated using an implanted opioid pump system and followed
up for a mean of 4.8 years.
- Pain control, quality of life of the patients,
and the cost of treatment in the year before and the year after implantation
were quantified.
|
| Results |
- The 40 patients were all suffering non-malignant
pain, mean duration 12.8 years. The main cause of pain was back pain
(23 patients); other common causes were pain in the extremities from
accidents (8 patients) and amputation (7 patients).
- In the 4.8 years after implantation, patients
experienced a 67% reduction in pain intensity on a visual analogue scale.
- Quality of life, as measured using the Karnofsky
scale, improved from 35% to 75%.
- Mean daily costs of treatment were reduced by
76%, because patients consumed less analgesic drugs, and required less
outpatient and emergency pain treatment.
|
| Discussion/Conclusion |
- Implantable-pump therapy produced a significant
and clinically satisfying reduction in patients' pain, which was associated
with a considerable increase in their quality of life.
- The costs of therapy were also lower than those
for conventional, oral therapy.
- The authors concluded that continuous
subarachnoid opioid therapy by means of implanted pump systems is highly
effective and much less expensive than other unsuccessful treatments
in chronic, non-malignant pain syndromes.
|
| Mueller-Schwefe
G, Hassenbusch SJ, Reig E |
| Cost Effectiveness of Intrathecal Therapy
for Pain. Neuromodulation 1999; 2: 77-84 |
| Discussion/Conclusion |
- This paper reviews studies demonstrating that
intrathecal opioid delivery is more cost-effective than other routes
of administration, in patients requiring pain management for longer
than 3-6 months.
- The SynchroMed infusion system was compared
with an external system (DuPen epidural catheter) in the management
of cancer and non-malignant pain; 15 patients were treated with the
intrathecal system and five with the epidural catheter. At 3 months,
costs of the two treatments were similar, but cost savings and cost
effectiveness accumulated in favour of the intrathecal system beyond
this point.
- Results supporting those above have also
been found in another study comparing an intrathecal with an external
system.
- In a cost-minimisation analysis model
of patients with cancer pain, oral and transdermal opioids were the
least expensive for the first 24 months of therapy, provided no dose
adjustments were required. However, once a dose increase was factored
into the model, oral and transdermal routes became more expensive than
intrathecal opioids after 10-18 months.
- A cost-effectiveness model of patients
with failed back surgery syndrome indicated that, in the base-case and
best-case estimates, intrathecal therapy was more cost-effective than
medical management after 22 and 11 months, respectively.
- In patients with non-cancer pain who had
received the SynchroMed implantable pump, indicators of quality of life
were significantly improved 1 year after pump implantation, and the
cost of healthcare was reduced.
- A cost analysis of 12 patients followed
up for 10-14 years showed that intrathecal delivery was more cost effective
than oral morphine administration in the long term.
- A study of intrathecal morphine and clonidine,
compared with oral morphine showed that, after 1 year of therapy, the
cost of intrathecal drug delivery was approximately 30% of that of oral
therapy. Intrathecal became more cost-effective than oral delivery after
4-6 months of treatment.
|
| Hassenbusch
SJ, Paice JA, Patt RB, Bedder MD, Bell GK |
| Clinical Realities and Economic Considerations:
Economics of Intrathecal Therapy. Journal of Pain and Symptom Management
1997; 14: S36-S48 |
| Discussion/Conclusion |
- Few economic analyses are available to
evaluate the cost-effectiveness of various modalities used to treat
chronic pain. Those that are available generally focus on short-, rather
than long-term therapy
- A model was designed to compare the costs
of different routes of delivery of opioids in cancer pain. This gave
a break-even time for oral and intrathecal therapies of 25 months (oral
and transdermal therapies were cheapest for short treatment durations).
However this break-even time was reduced to 10-18 months if small dose
escalations were built into the model.
- A second model for treatment of failed
back surgery syndrome, comparing intrathecal therapy with medical management,
demonstrated cost advantages for the intrathecal therapy, and a break-even
time of about 22 months.
- A study of patients receiving the SynchroMed
pump showed that, for several of the cohort, their quality of life improved,
as did the costs of health care in the year following implantation.
- A study of implantable technology for delivery
of ambulatory chemotherapy found the initial costs of the technology
to be much higher than those of externally delivered therapy. Nevertheless,
the cumulative charges for the implantable system were substantially
lower after 1 year. The break-even point was estimated to be 3 months.
- A comparison of implantable technology
versus a tunnelled epidural catheter in the management of pain again
showed smaller 1-year cumulative costs for the implantable pump, and
a break-even point of about 3 months.
|
| De
Lissovoy G, Brown RE, Halpern M, Hassenbusch SJ, Ross E |
| Cost-Effectiveness of Long-Term Intrathecal
Morphine Therapy for Pain Associated with Failed Back Surgery Syndrome.
Clinical Therapeutics 1997; 19: 96-112 |
| Method |
- The aim of the study was to estimate the direct
medical costs of intrathecal morphine therapy (IMT) administered via
an implantable pump, versus alternative, medical management.
- A decision-analytic model was constructed, on
the basis of a simulated cohort of 1000 patients with chronic intractable
pain attributed to failed back surgery syndrome. The time frame for
the model was up to 60 months.
- The model yielded monthly and cumulative
costs of care, averaged across all patients in the cohort.
|
| Results |
- When the costs of treatment and incidences
of adverse events were set at base-case values, the total expected cost
of IMT for 60 months was $82,893. The corresponding cost for the best-case
values was $53,468 per month, and was $125,102 per month for the worst-case
values. The cost of alternative treatment was $85,186.
- Because of initial expenditure, IMT becomes
more cost-effective as the duration of therapy increases. The base-case
cumulative costs were smaller than those of medical management after
22 months. The best-case cumulative costs were smaller after 11 months,
whereas the worst-case costs were never less expensive than medical
management.
|
| Discussion/Conclusion |
- The results indicated that IMT could produce
savings over medical therapy once treatment duration was longer than
about 1 year.
- The analysis was constrained by a lack of data
on the complications of IMT, lack of information on the natural history
of intractable pain, and on the effectiveness of treatment modalities
other than IMT. In addition, other important endpoints, such as social
functioning and return to employment, should be studied.
- IMT offers a promising therapeutic approach
for carefully selected candidates with chronic intractable pain.
|
| Bedder
MD, Burchiel K, Larson A |
| Cost Analysis of Two Implantable Narcotic
Delivery Systems. Journal of Pain and Symptom Management 1991; 6: 368-373 |
| Method |
- The aim of the study was compare average costs
of a type I implantable narcotic delivery system, utilising an external
infusion pump, and a type II system using a fully programmable implanted
infusion pump.
- Seven patients with cancer pain and eight
with non-malignant pain were treated with intrathecal narcotics via
an implantable pump (SynchroMed), five patients with cancer pain received
continuous morphine infusion via an exteriorised epidural catheter (DuPen).
|
| Results |
- Costs at 3 months for the exteriorised system
were $15,606.35, and for the internal system $16,316.00. Corresponding
costs at 6 months were $22,050.35 and $18,362.50, respectively. At 12
months, these were £34,938.35 and $21,368.30, respectively.
- Ongoing monthly costs were $2148 for the
exteriorised system and $273 for the internal pump.
|
| Discussion/Conclusion |
- The two systems had similar costs after 3 months
of treatment, but cost advantages accrued for the fully implantable
system after that. In addition, increasing drug requirements in patients
with cancer would produce further increases in the costs of the exteriorised
system, but little change in the cost of the internal system.
- The two types of systems were both effective
in reducing pain and patients' requirements for oral analgesics. It
therefore appears that the implantable pump was more cost-effective
than the exteriorised system when used for more than 3 months.
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